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UNDERGROUND STORAGE TANK <br /> SPILL CONTAINER TESTING REPORT FORM(Page 1 of 1) <br /> Type o=Action ❑ Installation Test <br /> ❑Repair Test ❑x 12 Month Test <br /> CERS ID I. FACILITY INFORMATION <br /> Date of Spill Container Test <br /> Business Name(Same as Facility Name or DBA-Doing Business As) 10/1/2019 <br /> Chevron <br /> Business Site Address City <br /> 8660 Lower Sac RD. zlP coae <br /> Stockton Ca. 95210 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) # <br /> Brian Roth <br /> Phone (916) 382-4761 <br /> Contractor/Tank Tester License# FICCCertification# <br /> ICC Certification Expiration Date <br /> 949066 8834817 10/19/2019 <br /> Spill Container Testing Training and Certifications(L/sl applicable certifications.) <br /> OPW <br /> III. SPILL CONTAINER TESTING INFORMATION <br /> Test Method Used: ❑x Manufacturer Guidelines(Specify): <br /> Hydrostatic with Measurement 1 HR no drop <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID: (By tanknumber,stored product,etc.) 87 91 diesel <br /> Spill Container Manufacturer: OPW OPS/ OPw <br /> Method of Cathodic Protection: ❑x Non-Metallic ❑x Non-Metallic ❑x Non-Metallic <br /> ❑Non-Metallic <br /> ❑ Isolation ❑Isolation ❑ Isolation <br /> ❑Isolation <br /> ❑Other(Specify in v) ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> Inside Diameter of Spill Container:(Inches) 12" 12" 12" <br /> Depth of Spill Container: (Inches) 13" 13" 13" <br /> Does the spill container have a 5 gallon capacity? ❑x Yes ❑No ❑x Yes ❑No Yes <br /> Method to Keep Spill Container Empty: ❑No Eify <br /> Z Drain Valve []Drain Valve ❑x Drain Valve <br /> ❑Onsite Pump ❑Onsite Pump ❑Onsite Pump <br /> ❑Other(Specify in V.) ❑Other(Specify in V.) ❑Other(Specify in V.) <br /> IV. SUMMARY OF TESTING RESULTS <br /> Spill Container Test Results: ❑x Pass ❑Fail 11 ❑x Pass [:]Fail ❑x Pass ❑ Fail ❑ Pass <br /> ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail'above must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations, Title 23, Division 3, <br /> Chapter 16,Section 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />